Immunization Record For Students Attending Post-Secondary Schools (Page 2 of 2) in pdf

HE LTH SERVICES

INFORMATION REGARDING MANDATORY

REQUIREMENT FOR ENROLLMENT

If you plan to enroll at Southwest Minnesota State University (SMSU), you are required by Minnesota Law

(M. S. 135A.14) to provide us with the month, day and year you were immunized against diphtheria, tetanus,

measles, mumps and rubella. Fill in these dates on the Student Immunization Record printed on the back of this

letter. Please be sure to use your full name, birth date and Mustang ID.

SMSU Health Services does not provide immunizations. You may obtain necessary immunizations from your

family physician/clinic or your local Public Health office. When all required immunizations have been obtained,

complete and return the form with the month, day and year that you received the immunizations.

To find out if you are adequately immunized against these diseases, check with your parents, family physician, or

school immunization records. Call your high school or doctor’s office for assistance if necessary.

An immunization may not be medically advisable for certain persons. If this applies to you, or if you have had any

of these diseases, Part 4 of the immunization form must be completed/signed by your doctor and returned to

SMSU Health Services.

Some people may be exempt from immunizations based on their religious or other conscientiously held beliefs. If

you request a conscientious exemption, you must have a notary witness your signature in Part 5 of the form before

returning it to SMSU Health Services.

You are legally required to supply the information requested, according to the instructions contained on the form.

A student who has submitted a compliant immunization record to another Minnesota post-secondary school may

complete Part 2.

Anyone enrolled at SMSU who fails to submit the required information within 45 days of the beginning of the term

will not be allowed to remain enrolled at SMSU.

If you have questions about the immunization law or your status of compliance, please contact Health Services at

507-537-7202.

SMSU Health Services

COMPLETE THE STUDENT IMMUNIZATION

Bellows Academic 158

RECORD PRINTED ON THE BACK OF THIS

1501 State Street

LETTER AND RETURN IMMEDIATELY TO:

Marshall, MN 56258

Telephone (507) 537-7202 • (507) 537-7259

1501 State Street, Marshall, MN 56258 •

8/14

A member of the Minnesota State Colleges & Universities System. SMSU is an equal opportunity educator & employer. ADA Accessible.

Immunization Record For Students Attending Post-Secondary Schools Page 2